Basic Information
Provider Information | |||||||||
NPI: | 1568659118 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKIRNAN | ||||||||
FirstName: | TIFFANY | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HEHMEYER | ||||||||
OtherFirstName: | TIFFANY | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1001 BELLEFONTAINE AVE | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458042800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199984575 | ||||||||
FaxNumber: | 4199984586 | ||||||||
Practice Location | |||||||||
Address1: | 1005 BELLEFONTAINE AVE STE 225 | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458042896 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199988244 | ||||||||
FaxNumber: | 4199988243 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2007 | ||||||||
LastUpdateDate: | 01/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 10000963A | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 085003049 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 50003777 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.